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LETTERS TO THE EDITOR
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: LPSP is the sole author of this paper. Sponsor’s Role: None.
REFERENCES 1. Bahat G. Risk of proton pump inhibitor–induced mild hyponatremia in older adults. J Am Geriatr Soc 2014;62:1206–1207. 2. Buon M, Gaillard C, Martin J et al. Risk of proton pump inhibitor– induced mild hyponatremia in older adults. J Am Geriatr Soc 2013;61:2052–2054.
COMMENT ON “SARCOPENIC OBESITY AND RISK OF CARDIOVASCULAR DISEASE AND MORTALITY: A POPULATION-BASED COHORT STUDY OF OLDER MEN” To the Editor: We read with interest the article by Atkins and colleagues,1 who reported an association between sarcopenia, central obesity, and all-cause and cardiovascular mortality in elderly men. They also found that the greatest risk of all-cause mortality occurred in obese individuals with sarcopenia. The results are particularly important because the prevalence of sarcopenia was reported to be up to 84% in different elderly male cohorts.2 Nevertheless, some methodological concerns need to be acknowledged. First, the method of diagnosing sarcopenia relied on an equation involving midarm muscle circumference (MAMC; mid-upper arm circumference (cm)–0.3142 9 triceps skinfold thickness (mm)), which had previously been found to be strongly correlated with dual-energy X-ray absorptiometry (DEXA),3 although that study was conducted in individuals undergoing hemodialysis and not in healthy individuals. Moreover, an earlier study reported a weaker correlation (correlation coefficients=0. 24–0.36) for MAMC and DEXA based on lean tissue masses in healthy postmenopausal women.4 Second, the study by Atkins and colleagues defined subjects with sarcopenia as those in the lowest two-fifths of the MAMC distribution. This statistical approach may not be consistent with earlier studies in which sarcopenia was defined as the lowest two quintiles the of entire population.5,6 Third, MAMC relies on anthropometric measurements, but the European Working Group on Sarcopenia in Older People clearly recommended against routine use of anthropometric measurements in the diagnosis of sarcopenia.7 Therefore, although the sample size seems to be satisfactory even for skewed parameters, a more-accurate diagnosis of sarcopenia might have led to more-robust results in this study. Umut Safer, MD Department of Geriatrics, Gulhane School of Medicine, Ankara, Turkey
JUNE 2014–VOL. 62, NO. 6
JAGS
Ilker Tasci, MD Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey Vildan Binay Safer, MD Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Research and Training Hospital, Ankara, Turkey
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors discussed and prepared the manuscript. Sponsor’s Role: None.
REFERENCES 1. Atkins JL, Whincup PH, Morris RW et al. Sarcopenic obesity and risk of cardiovascular disease and mortality: A population-based cohort study of older men. J Am Geriatr Soc 2014;62:253–260. 2. Batsis JA, Barre LK, Mackenzie TA et al. Variation in the prevalence of sarcopenia and sarcopenic obesity in older adults associated with different research definitions: Dual-energy X-ray absorptiometry data from the National Health and Nutrition Examination Survey 1999–2004. J Am Geriatr Soc 2013;61:974–980. 3. Noori N, Kopple JD, Kovesdy CP et al. Mid-arm muscle circumference and quality of life and survival in maintenance hemodialysis patients. Clin J Am Soc Nephrol 2010;5:2258–2268. 4. Zoico E, Di Francesco V, Guralnik JM et al. Physical disability and muscular strength in relation to obesity and different body composition indexes in a sample of healthy elderly women. Int J Obes Relat Metab Disord 2004;28:234–241. 5. Davison KK, Ford ES, Cogswell ME et al. Percentage of body fat and body mass index are associated with mobility limitations in people aged 70 and older from NHANES III. J Am Geriatr Soc 2002;50:1802–1809. 6. Kim TN, Yang SJ, Yoo HJ et al. Prevalence of sarcopenia and sarcopenic obesity in Korean adults: The Korean Sarcopenic Obesity Study. Int J Obes 2009;33:885–892. 7. Cruz-Jentoft AJ, Baeyens JP, Bauer JM et al. Sarcopenia: European consensus on definition and diagnosis. Age Ageing 2010;39:412–442.
RESPONSE TO SAFER ET AL. To the Editor: We thank Dr. Safer and colleagues for their interest in our recent report on sarcopenic obesity.1 Safer and colleagues note that the European Working Group on Sarcopenia in Older People does not recommend assessment of midarm muscle circumference (MAMC) for the diagnosis of sarcopenia.2 Our report was based on MAMC because, in this population-based study in widely dispersed primary care settings, it was not possible to use a criterion standard measure of muscle mass, such as dual-energy X-ray absorptiometry (DXA), computed tomography or magnetic resonance imaging. Moreover, the American Heart Association recognizes the validity of upper-arm anthropometric measures for the assessment of muscle mass.3 Although the study by Noori, reporting an association between MAMC and lean mass from DXA,4 was based in a very specific
JAGS
JUNE 2014–VOL. 62, NO. 6
patient population, this and the other study that examined the association between MAMC and criterion standard measurements of lean mass5 have reported positive rather than null or inverse associations, suggesting that MAMC is a valid, if imprecise, measure of sarcopenia. Furthermore, DXA-based lean mass6,7 and MAMC1,8,9 show similar patterns of association with mortality, reinforcing the case for the validity of MAMC. Safer and colleagues also suggest that our definition of sarcopenia as being in the lowest two-fifths (40%) of the MAMC distribution “may not be consistent with earlier studies in which sarcopenia is defined as the lowest two quintiles of the entire population.”10,11 In both previous studies cited, sarcopenia was defined as the lowest 40% of skeletal muscle mass in the study population. Although different approaches were used to assess muscle mass in the two studies, the statistical approaches taken to defining sarcopenia in those reports appear to have been consistent with our own. Moreover, our approach, as noted in the Discussion, yielded a cutoff for defining sarcopenia broadly similar to that in another recent population-based study.8 Overall, we agree with the implication of Safer and colleagues’ comments that prospective studies with moreaccurate measures of sarcopenia will help to define the magnitude of the associations between sarcopenia, mortality, and other outcomes more precisely. Janice L. Atkins, MSc Department of Primary Care and Population Health, University College London, London, UK Peter H. Whincup, PhD Population Health Research Centre, Division of Population Health Sciences and Education, St George’s, University of London, London, UK Richard W. Morris, PhD S. Goya Wannamethee, PhD Department of Primary Care and Population Health, University College London, London, UK
ACKNOWLEDGMENTS Conflict of Interest: The authors do not have any conflicts of interest to disclose. Author Contributions: JLA, PHW, RWM, and SGW discussed and prepared the manuscript. Sponsor’s Role: None.
REFERENCES 1. Atkins JL, Whincup PH, Morris RW et al. Sarcopenic obesity and risk of cardiovascular disease and mortality: A population-based cohort study of older men. J Am Geriatr Soc 2014;62:253–260. 2. Cruz-Jentoft AJ, Baeyens JP, Bauer JM et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412–423. 3. Cornier MA, Despres JP, Davis N et al. Assessing adiposity a scientific statement from the American Heart Association. Circulation 2011;124:1996–2019. 4. Noori N, Kopple JD, Kovesdy CP et al. Mid-arm muscle circumference and quality of life and survival in maintenance hemodialysis patients. Clin J Am Soc Nephrol 2010;5:2258–2268.
LETTERS TO THE EDITOR
1209
5. Reid IR, Evans MC, Ames R. Relationships between upper-arm anthropometry and soft-tissue composition in postmenopausal women. Am J Clin Nutr 1992;56:463–466. 6. Wijnhoven HA, Snijder MB, van Bokhorst-de van der Schueren MA et al. Region-specific fat mass and muscle mass and mortality in communitydwelling older men and women. Gerontology 2012;58:32–40. 7. Bunout D, de la Maza MP, Barrera G et al. Association between sarcopenia and mortality in healthy older people. Australas J Ageing 2011;30:89– 92. 8. Landi F, Russo A, Liperoti R et al. Midarm muscle circumference, physical performance and mortality: Results from the aging and longevity study in the Sirente geographic area (ilSIRENTE study). Clin Nutr 2010;29:441–447. 9. Wannamethee SG, Shaper AG, Lennon L et al. Decreased muscle mass and increased central adiposity are independently related to mortality in older men. Am J Clin Nutr 2007;86:1339–1346. 10. Davison KK, Ford ES, Cogswell ME et al. Percentage of body fat and body mass index are associated with mobility limitations in people aged 70 and older from NHANES III. J Am Geriatr Soc 2002;50:1802–1809. 11. Kim TN, Yang SJ, Yoo HJ et al. Prevalence of sarcopenia and sarcopenic obesity in Korean adults: The Korean Sarcopenia Obesity Study. Int J Obes 2009;33:885–892.
NUTRITIONAL STATUS AND PRESSURE ULCERS. RISK ASSESSMENT AND ESTIMATION IN OLDER ADULTS To the Editor: We read with much interest the paper by Yatabe and colleagues1 on the usefulness of the Mini Nutritional Assessment and of plasmatic amino acid scores to predict the risk of developing pressure ulcers (PUs) in elderly adults in the hospital. Despite the interesting subject and the innovative aim of the study, we observed certain biases that hinder interpretation of the results. In geriatrics, there are a number of validated scales designed specifically for elderly people that allow the development of a good nutritional history. The Subjective Global Assessment (SGA)2 and the Mini Nutritional Assessment (MNA)3 are among the most widely used, with the latter being the reference scale for elderly adults living in the community and in other environments.4 The authors refer to the MNA but used the MNA-Short Form (MNA-SF) in their study, a scale validated for screening of undernutrition in geriatric practice.5 Pressure ulcers are defined as “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.”6 A number of instruments have been developed to assess for risk of PUs. The two most widely used instruments are the Braden Scale (six items; total score range 6–23) and the Norton scale (five items; total score range 5–20).7 In Yatabe and colleagues’ article,1 the Braden Scale was administered to 239 of the 422 subjects, only in those with a SGA indicating moderate or severe malnutrition. The Braden Scale was not administered to 43% of subjects, in 13 of the 30 subjects who developed PUs. This makes it impossible to establish the main aim of their study. Another important limitation that reduced the sample size was that blood amino acid concentrations, vitamins, and trace elements was only assessed in subjects with a Braden score less than 15 (only 17 of the 30 subjects with PUs and not 27 as reported in Table 4). This prevented achieving the secondary aim of
LETTERS TO THE EDITOR
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: LPSP is the sole author of this paper. Sponsor’s Role: None.
REFERENCES 1. Bahat G. Risk of proton pump inhibitor–induced mild hyponatremia in older adults. J Am Geriatr Soc 2014;62:1206–1207. 2. Buon M, Gaillard C, Martin J et al. Risk of proton pump inhibitor– induced mild hyponatremia in older adults. J Am Geriatr Soc 2013;61:2052–2054.
COMMENT ON “SARCOPENIC OBESITY AND RISK OF CARDIOVASCULAR DISEASE AND MORTALITY: A POPULATION-BASED COHORT STUDY OF OLDER MEN” To the Editor: We read with interest the article by Atkins and colleagues,1 who reported an association between sarcopenia, central obesity, and all-cause and cardiovascular mortality in elderly men. They also found that the greatest risk of all-cause mortality occurred in obese individuals with sarcopenia. The results are particularly important because the prevalence of sarcopenia was reported to be up to 84% in different elderly male cohorts.2 Nevertheless, some methodological concerns need to be acknowledged. First, the method of diagnosing sarcopenia relied on an equation involving midarm muscle circumference (MAMC; mid-upper arm circumference (cm)–0.3142 9 triceps skinfold thickness (mm)), which had previously been found to be strongly correlated with dual-energy X-ray absorptiometry (DEXA),3 although that study was conducted in individuals undergoing hemodialysis and not in healthy individuals. Moreover, an earlier study reported a weaker correlation (correlation coefficients=0. 24–0.36) for MAMC and DEXA based on lean tissue masses in healthy postmenopausal women.4 Second, the study by Atkins and colleagues defined subjects with sarcopenia as those in the lowest two-fifths of the MAMC distribution. This statistical approach may not be consistent with earlier studies in which sarcopenia was defined as the lowest two quintiles the of entire population.5,6 Third, MAMC relies on anthropometric measurements, but the European Working Group on Sarcopenia in Older People clearly recommended against routine use of anthropometric measurements in the diagnosis of sarcopenia.7 Therefore, although the sample size seems to be satisfactory even for skewed parameters, a more-accurate diagnosis of sarcopenia might have led to more-robust results in this study. Umut Safer, MD Department of Geriatrics, Gulhane School of Medicine, Ankara, Turkey
JUNE 2014–VOL. 62, NO. 6
JAGS
Ilker Tasci, MD Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey Vildan Binay Safer, MD Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Research and Training Hospital, Ankara, Turkey
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors discussed and prepared the manuscript. Sponsor’s Role: None.
REFERENCES 1. Atkins JL, Whincup PH, Morris RW et al. Sarcopenic obesity and risk of cardiovascular disease and mortality: A population-based cohort study of older men. J Am Geriatr Soc 2014;62:253–260. 2. Batsis JA, Barre LK, Mackenzie TA et al. Variation in the prevalence of sarcopenia and sarcopenic obesity in older adults associated with different research definitions: Dual-energy X-ray absorptiometry data from the National Health and Nutrition Examination Survey 1999–2004. J Am Geriatr Soc 2013;61:974–980. 3. Noori N, Kopple JD, Kovesdy CP et al. Mid-arm muscle circumference and quality of life and survival in maintenance hemodialysis patients. Clin J Am Soc Nephrol 2010;5:2258–2268. 4. Zoico E, Di Francesco V, Guralnik JM et al. Physical disability and muscular strength in relation to obesity and different body composition indexes in a sample of healthy elderly women. Int J Obes Relat Metab Disord 2004;28:234–241. 5. Davison KK, Ford ES, Cogswell ME et al. Percentage of body fat and body mass index are associated with mobility limitations in people aged 70 and older from NHANES III. J Am Geriatr Soc 2002;50:1802–1809. 6. Kim TN, Yang SJ, Yoo HJ et al. Prevalence of sarcopenia and sarcopenic obesity in Korean adults: The Korean Sarcopenic Obesity Study. Int J Obes 2009;33:885–892. 7. Cruz-Jentoft AJ, Baeyens JP, Bauer JM et al. Sarcopenia: European consensus on definition and diagnosis. Age Ageing 2010;39:412–442.
RESPONSE TO SAFER ET AL. To the Editor: We thank Dr. Safer and colleagues for their interest in our recent report on sarcopenic obesity.1 Safer and colleagues note that the European Working Group on Sarcopenia in Older People does not recommend assessment of midarm muscle circumference (MAMC) for the diagnosis of sarcopenia.2 Our report was based on MAMC because, in this population-based study in widely dispersed primary care settings, it was not possible to use a criterion standard measure of muscle mass, such as dual-energy X-ray absorptiometry (DXA), computed tomography or magnetic resonance imaging. Moreover, the American Heart Association recognizes the validity of upper-arm anthropometric measures for the assessment of muscle mass.3 Although the study by Noori, reporting an association between MAMC and lean mass from DXA,4 was based in a very specific
JAGS
JUNE 2014–VOL. 62, NO. 6
patient population, this and the other study that examined the association between MAMC and criterion standard measurements of lean mass5 have reported positive rather than null or inverse associations, suggesting that MAMC is a valid, if imprecise, measure of sarcopenia. Furthermore, DXA-based lean mass6,7 and MAMC1,8,9 show similar patterns of association with mortality, reinforcing the case for the validity of MAMC. Safer and colleagues also suggest that our definition of sarcopenia as being in the lowest two-fifths (40%) of the MAMC distribution “may not be consistent with earlier studies in which sarcopenia is defined as the lowest two quintiles of the entire population.”10,11 In both previous studies cited, sarcopenia was defined as the lowest 40% of skeletal muscle mass in the study population. Although different approaches were used to assess muscle mass in the two studies, the statistical approaches taken to defining sarcopenia in those reports appear to have been consistent with our own. Moreover, our approach, as noted in the Discussion, yielded a cutoff for defining sarcopenia broadly similar to that in another recent population-based study.8 Overall, we agree with the implication of Safer and colleagues’ comments that prospective studies with moreaccurate measures of sarcopenia will help to define the magnitude of the associations between sarcopenia, mortality, and other outcomes more precisely. Janice L. Atkins, MSc Department of Primary Care and Population Health, University College London, London, UK Peter H. Whincup, PhD Population Health Research Centre, Division of Population Health Sciences and Education, St George’s, University of London, London, UK Richard W. Morris, PhD S. Goya Wannamethee, PhD Department of Primary Care and Population Health, University College London, London, UK
ACKNOWLEDGMENTS Conflict of Interest: The authors do not have any conflicts of interest to disclose. Author Contributions: JLA, PHW, RWM, and SGW discussed and prepared the manuscript. Sponsor’s Role: None.
REFERENCES 1. Atkins JL, Whincup PH, Morris RW et al. Sarcopenic obesity and risk of cardiovascular disease and mortality: A population-based cohort study of older men. J Am Geriatr Soc 2014;62:253–260. 2. Cruz-Jentoft AJ, Baeyens JP, Bauer JM et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412–423. 3. Cornier MA, Despres JP, Davis N et al. Assessing adiposity a scientific statement from the American Heart Association. Circulation 2011;124:1996–2019. 4. Noori N, Kopple JD, Kovesdy CP et al. Mid-arm muscle circumference and quality of life and survival in maintenance hemodialysis patients. Clin J Am Soc Nephrol 2010;5:2258–2268.
LETTERS TO THE EDITOR
1209
5. Reid IR, Evans MC, Ames R. Relationships between upper-arm anthropometry and soft-tissue composition in postmenopausal women. Am J Clin Nutr 1992;56:463–466. 6. Wijnhoven HA, Snijder MB, van Bokhorst-de van der Schueren MA et al. Region-specific fat mass and muscle mass and mortality in communitydwelling older men and women. Gerontology 2012;58:32–40. 7. Bunout D, de la Maza MP, Barrera G et al. Association between sarcopenia and mortality in healthy older people. Australas J Ageing 2011;30:89– 92. 8. Landi F, Russo A, Liperoti R et al. Midarm muscle circumference, physical performance and mortality: Results from the aging and longevity study in the Sirente geographic area (ilSIRENTE study). Clin Nutr 2010;29:441–447. 9. Wannamethee SG, Shaper AG, Lennon L et al. Decreased muscle mass and increased central adiposity are independently related to mortality in older men. Am J Clin Nutr 2007;86:1339–1346. 10. Davison KK, Ford ES, Cogswell ME et al. Percentage of body fat and body mass index are associated with mobility limitations in people aged 70 and older from NHANES III. J Am Geriatr Soc 2002;50:1802–1809. 11. Kim TN, Yang SJ, Yoo HJ et al. Prevalence of sarcopenia and sarcopenic obesity in Korean adults: The Korean Sarcopenia Obesity Study. Int J Obes 2009;33:885–892.
NUTRITIONAL STATUS AND PRESSURE ULCERS. RISK ASSESSMENT AND ESTIMATION IN OLDER ADULTS To the Editor: We read with much interest the paper by Yatabe and colleagues1 on the usefulness of the Mini Nutritional Assessment and of plasmatic amino acid scores to predict the risk of developing pressure ulcers (PUs) in elderly adults in the hospital. Despite the interesting subject and the innovative aim of the study, we observed certain biases that hinder interpretation of the results. In geriatrics, there are a number of validated scales designed specifically for elderly people that allow the development of a good nutritional history. The Subjective Global Assessment (SGA)2 and the Mini Nutritional Assessment (MNA)3 are among the most widely used, with the latter being the reference scale for elderly adults living in the community and in other environments.4 The authors refer to the MNA but used the MNA-Short Form (MNA-SF) in their study, a scale validated for screening of undernutrition in geriatric practice.5 Pressure ulcers are defined as “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.”6 A number of instruments have been developed to assess for risk of PUs. The two most widely used instruments are the Braden Scale (six items; total score range 6–23) and the Norton scale (five items; total score range 5–20).7 In Yatabe and colleagues’ article,1 the Braden Scale was administered to 239 of the 422 subjects, only in those with a SGA indicating moderate or severe malnutrition. The Braden Scale was not administered to 43% of subjects, in 13 of the 30 subjects who developed PUs. This makes it impossible to establish the main aim of their study. Another important limitation that reduced the sample size was that blood amino acid concentrations, vitamins, and trace elements was only assessed in subjects with a Braden score less than 15 (only 17 of the 30 subjects with PUs and not 27 as reported in Table 4). This prevented achieving the secondary aim of
